ESI Scheme Benefits: medical benefits | employment injury | maternity

ESI Scheme Benefits: What are ‘contribution periods’ and ‘benefit periods’?: A financial year is divided into two six months span, i.e., April to September and October to March. Each of the six monthly period is called a ‘contribution period’. Similarly, a calendar year is divided into two six monthly span, i.e., January to June and July to December, with each of the six monthly period being called a ‘benefit period’. For the contribution paid in the contribution period from April to September, an IP would be eligible for benefit in the period from January to June.

Similarly, for the contribution paid in the period from July to December, the IP becomes entitled to benefits in the benefit period from July to December. Thus, the entitlement to benefits of an IP during a benefit period is decided based upon the number of days for which contribution is being paid in the contribution period corresponding to the benefit period.

How superior is the ESI Scheme as compared to the Mediclaim policy / Group mediclaim policy issued by the general insurance companies ?

The benefits under the ESI Scheme are far superior as compared with the risks covered under the mediclaim policies. Medical care is only one of the many benefits available to the beneficiaries under the Scheme. Even this one benefit comes out far superior when compared with the mediclaim policies, as detailed below:

Commercial medical insurance ESI Scheme – medical benefit
Commercial motive Welfare motive
Premium based on age, sum insured & claims Experience Uniform rate of contribution for all age groups
Medical check up reqd. for certain persons No medical checkup required for anyone
Ceiling on overall benefit (sum insured) as well as compartmental limits No limit on medical benefit
Exclusions prescribed No exclusions
Extra premium for covering family of insured person (IP) Family members of IP covered at no extra cost
Only medical benefit Provides many benefits in addition to medical benefitq
Choice of class of treatment(general ward, pvt. / semi pvt. ward, etc.) No choice of class of treatment-only general ward

What is medical benefit?

Medical benefit means medical care to the IPs and their families. Medical benefit is provided in kind through a network of hospitals and dispensaries coming under the administrative control of the State Government and through ESIC Model Hospitals and Hospitals coming under the administrative control of the ESI Corporation. This benefit is uniform to all according to their requirement without disparity or linking it to their wages and contributions paid. It is the only health insurance scheme in the world, which has no upper ceiling on expenditure on medical care of beneficiaries.

What are the eligibility conditions to become entitled to medical benefit?

A person who is covered under the scheme for the first time is eligible for medical care for self and family for three months. If, he /she continue in insurable employment for three months or more, the benefit is admissible till the beginning of the corresponding benefit period. If the insured person is under ESI coverage for at least two years and contributed for not less than 156 days, and is suffering from any of the 34 specified long term diseases, the medical benefit is admissible till the incapacity lasts or for a period of 2 years for self and family.

Whether the family members of the IP who are staying in a different place from that of the IP avail medical care in their place of residence ?

In case the family members of the IP are staying in a different town / city from that of the IP, and this fact is declared online by the employer, they can avail medical facilities of ESI Scheme in a dispensary located near their residence with the pehchan card. (the IPs are given a set of two pehchan cards).

What is the procedure to avail medical benefit when an insured person leaves station for a temporary period ?

While leaving the station, the insured person may obtain a certificate of employment from his employer in Form ESIC – 105. Based on this certificate and pehchan card, the insured person can avail medical benefit in any ESI Dispensary/Hospital across the country. On the basis of the Pehchan card, the insured person and his /her family can avail medical benefit in any ESI Dispensary/Hospital after the computerisation process is completed.

How are medical treatment administered to the beneficiaries if any of the ESI hospitals are not having the requisite facilities (super specialty treatment) ?

The State Medical Commissioner/Medical Superintendents of ESIC Hospitals/Director, ESI (Medical) Services, have entered into tie-up arrangements with recognized medical institutions to provide cashless treatment to insured persons and their family members for treatment that are not available in ESI/ESIC institutions to ensure that the ESI beneficiaries are provided full medical care. In order to avail treatment in such hospitals, the insured persons are required to obtain eligibility certificate from the concerned Insurance Medical Officer of ESI/ESIC hospital, referring the insured person or his dependents to such hospitals.

What are the eligibility conditions for availing the super specialty treatment ? The eligibility conditions are as follows:

  • An insured person who is eligible for medical treatment is entitled to avail Super Speciality treatment, for self and his/her family.
  • A newly registered employee is entitled to avail super speciality treatment for self, on completion of three months of service in insurable employment and
  • contribution should have been paid/payable for not less than 39 days during that period.
  • A newly registered employee ‘s dependents are entitled to super speciality treatment on completion of six months of service in insurable employment and contribution should have been paid/payable for not less than 78 days during that period.
  • The concepts of contribution period and benefit period will not apply while deciding the eligibility of an IP for Super specialty treatment.

Whether a beneficiary can avail the super specialty treatment in a state different from that of the state in which the IP is registered ?

Yes. The procedure for the same is as follows:

  • The referring hospital/dispensary shall send a copy of the reference slip to the SSMC/SMC of the referring and the referred state from where the patient wants to avail, the required super-speciality treatment.
  • SSMC/SMC of the state from where the patient wants to take treatment, shall intimate the network/tie-up hospital for providing necessary/required treatment. Thereafter, the bill for payment may be sent to the SSMC/SMC of the state from where he was referred on completion of treatment.

A brief note on the infrastructure for ESIC for extending medical care to the beneficiaries.

Since the inception of the scheme, the infrastructural network of the Scheme has been expanding to meet the social security requirements of an ever increasing worker population. Full range of medical, surgical and obstetric treatment consisting of out-door treatment, in-patient treatment, supply of all drugs and dressings, pathological and radiological investigations, prenatal and post-natal care, super speciality consultation and treatment, ambulance services, provision of artificial appliances etc are provided to the ESI beneficiaries through a network of dispensaries/hospitals and recognized medical institutions where tie-up arrangements have been entered into to provide cashless treatment.

The ESIC hospitals at Rajajinagar and Peenya and ESI Hospital at Indiranagar in Bangalore have been provided with sophisticated equipments for detection and treatment of various diseases. ESI Hospital at Indiranagar has facility for dialysis and the ESIC hospital at Rajajinagar has been modernized and has upgraded facilities viz., C.T. Scan, MRI, Blood bank, ICU. centralized gas pipe line, modern laundry and kitchen. Further, ESIC has entered into MOU with Jayadeva Institute of Cardiology and commissioned cardiac centre at ESIC Model Hospital.

What is sickness benefit?

Sickness signifies a state of health necessitating medical treatment and attendance and abstention by the IP from work on medical grounds. Financial support extended by the ESI Corporation in such a contingency is called Sickness Benefit. This benefit is paid for the period of abstention, duly certified by the Authorized Medical Officer.

What are the eligibility conditions for availing sickness benefit ?

The eligibility criterion for availing sickness benefit are as follows :-

  • On completion of nine months in insurable employment.
  • Should have paid contributions for not less than 78 days in the corresponding contribution period.
  • Eligible for 91 days Sickness Benefit in two consecutive benefit periods.
  • Benefit is not paid for an initial period of two days during the certified period of illness known as waiting days.

If the insured person is certified sick within 15 days of the last spell, the waiting period is not reckoned and benefit is payable from the beginning of the spell.

What is the quantum of sickness benefit payable ?

Sickness Benefit is payable @ 70% of the average daily wages of the IP.

What is Extended Sickness Benefit ?

Extended Sickness Benefit is paid for prolonged illness due to 34 specified diseases, over and above the sickness benefit. Extended sickness benefit may also be sanctioned by the prescribed authority in case of any rare disease or special circumstances on the recommendation of the specified authority.

What are the conditions for availing Extended Sickness Benefit ?

The eligibility criteria for availing Extended Sickness Benefit are:

  • Should be an insured person on the date of commencement of spell of extended sickness benefit.
  • Should have been employed continuously for a period of 2 years or more in covered factory or establishment.
  • Continuous employment means that the insured person should have completed four contribution periods immediately preceding the spell of sickness.
  • Contributions should have been paid/payable for 156 days in the above said four contribution period.
  • The insured person should be eligible to claim sickness benefit in at least one of the four contribution periods

The above conditions may be relaxed on humanitarian grounds, subject to sanction by the appropriate authority and based on the following criterion:-

  • Those who have not completed two years but have paid contributions for 156 days and also qualified for SB in one of the contribution periods.
  • Those who have completed two years and also paid contributions for 156 days, but are not eligible for SB in any contribution period.

What is the scale of Extended Sickness Benefit payable ?

The scale of benefit is as follows :-

  • After exhausting 91 days of Sickness Benefit, ESB is payable upto 124/309 days i.e., which includes SB for 91 upto 400 days.
  • Upto 2 years ie., 730 days in special circumstances or till the insured person attains 60 years, whichever is earlier, subject to recommendations of the appropriate authority.
  • Payable @ 80% of average daily wages.

The scale of benefit is as follows :-

  • After exhausting 91 days of Sickness Benefit, ESB is payable upto 124/309 days i.e., which includes SB for 91 upto 400 days.
  • Upto 2 years ie., 730 days in special circumstances or till the insured person attains 60 years, whichever is earlier, subject to recommendations of the appropriate authority.
  • Payable @ 80% of average daily wages.

What is enhanced sickness benefit and who can be availed?

To promote the norms of small family, this cash benefit is paid to the insured person for undergoing vasectomy/tubectomy operation. The eligibility criteria and scale of benefit are :-

  • Should have paid contributions for not less than 78 days in the corresponding contribution period.
  • Benefit payable for 14 days for tubectomy and 7 days for vasectomy.
  • For post operative complications of tubectomy, benefit can be extended by the appropriate authority beyond 21 days.
  • Benefit is payable @ 100% of average daily wages.

What is an employment injury ?

It is a personal injury caused by an accident or occupational disease arising out of and in the course of his insurable employment within or outside territorial limits of India. The law relating to employment injury has been liberalized. An accident arising in the course of employment is presumed also to have arisen out of employment if there is no evidence to the contrary. An accident which may occur while commuting between the place of residence and workplace is also treated as notional extension of employment, and as a result, and the injury sustained from such an accident is construed as employment injury, if, the nexus between the time, place and circumstances and employment is established, for purpose of disablement or death benefit

Whether the employer is entitled to claim reimbursement in respect of first aid, medical care and transport of the IP who has sustained employment injury ?

Yes. The employer, could furnish the claim along with the supporting document in respect of the expenditure incurred, along with the undertaking from the IP that he / she has not borne any of the expenditure for which reimbursement is being claimed by the employer. The employer should also ensure that Accident report in form-12 is submitted to the branch office to which it is attached to, at the earliest (the report may also be submitted online).

What is disablement ?

Disablement is a condition resulting from employment injury which may render the insured persons disabled. The various types of disablement are:

  • i. Temporary disablement – rendering an insured person incapable of work temporarily and necessitating medical treatment.
  • ii. Permanent Partial disablement – reducing the earning capacity of the insured person.
  • iii. Permanent Total disablement – totally depriving the insured person of the power to do any work.

Which of the diseases fall under the category ‘ occupational diseases’ ?

Occupational diseases are such diseases that the IP is susceptible to as a result of engaging in a specific occupation. Contracting any disease while in employment for a specified period in any of the industries listed in Part, A, B & C of Schedule III of the ESI Act, which enumerates the industrial processes involving exposure to the diseases and the corresponding compensable occupational diseases, are thus recognized for payment of disablement benefits without any further evidence.

What is Temporary Disablement Benefit ?

It is a periodical payment to an insured person suffering from disablement as a result of employment injury for the period of abstention from work certified by an authorized Medical Officer. The salient features and scale of benefit are as follows:-

  • From the very first day of entering into insurable employment, the insured person is entitled to this benefit irrespective of having paid any contribution.
  • Temporary Disablement Benefit is payable to the insured person after the accident is accepted as employment injury.
  • The benefit is payable as long as the temporary disablement lasts and is duly certified.
  • The quantum of benefit is 90% of average daily wages.

What is Permanent Disablement Benefit ?

Due to employment injury, if an insured person has any residual disability of permanent nature, the insured person is referred to a medical board and the loss of earning capacity is assessed, if any, as per Schedule II of the ESI Act, as well as non-scheduled injuries resulting from employment injury. Thereafter the insured person is paid monthly periodical payments of permanent disablement for life from the date of termination of temporary disablement benefit at the percentage awarded by the Medical Board out of the full daily rate of temporary disablement benefit. In case, the insured person has not been certified temporarily disabled between the date of injury and the date of assessment by the medical board, permanent disablement if assessed is payable from the following date of employment injury due to accident.

How is Permanent Disablement Benefit disbursed to the IPs ?

The benefit is processed by the Regional Office /Sub Regional Offices/Divisional Office and credited to the bank account of the insured person every month. Payments are disbursed by Branch Offices in respect of cases not processed RO/SRO/DO. The insured person can also opt for the payment in lump sum, if his daily rate of Permanent disablement benefit does not exceed rupees five per day or in case it exceeds rupees five per day, but the commuted value does not exceed rupees thirty thousand. The insured person is required to submit life certificate once a year during the month of January every year and an amount of Rs.100/- would be paid as conveyance to the concerned insured person.

What is maternity benefit ?

Maternity Benefit is cash payable to an insured woman for a specified period of abstention from work, due to confinement, miscarriage or sickness arising out of pregnancy, pre-mature birth of child or miscarriage or confinement. ‘Confinement’ connotes labour resulting in the delivery of a living child or labour after 26 weeks of pregnancy whether the resultant issue is alive or dead.

‘Miscarriage’ means expulsion of the contents of a pregnant uterus at any period prior to or during the 26th week of pregnancy. Criminal abortion or miscarriage does not entitle the insured woman the benefit.

What are the conditions subject to which maternity benefit is payable ?

The conditions for availing maternity benefit are as follows:

  • Payment of contribution for not less than 70 days in the immediately preceding two contribution periods.
  • Confinement should actually occur or expected to occur in a benefit period relevant to the insured woman, i.e., if she actually confines or expected to confine before the start of the first benefit period, is not entitled to claim, even though, a part of the maternity leave will fall within her first benefit period.
  • if an insured woman’s actual date or expected date of confinement, falls within her first benefit period, she will be entitled to maternity benefit even if a part of the maternity leave may fall before the start of the first benefit period.
  • Upto 12 weeks in the case of normal delivery, upto 6 weeks in the case of miscarriage. Extendable by 4 weeks on medical advice.
  • Benefit payable at almost 100% of average daily wages.
  • Benefit is paid only if the insured woman does not work for remuneration during the period for which benefit is claimed irrespective whether she received any leave wages also for the days of abstention or was on strike during the same period.

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